HIV, drugs and the legal environment

 Steffanie A. Strathdee (University of California San Diego, La Jolla,

CA, USA),  

Leo Beletsky (Northeastern University School of Law and Bouvé College of Health Sciences, Boston, U.S),

 Thomas Kerr (University of British Columbia, Canada)

Overview1. Introduction2. Drug-Related Laws and Policies that Influence HIV Risk Behaviors3. Policing Practices and HIV Risks4. Avenues for Intervention5. Conclusions/Recommendations

The HIV risk environment • Levels:

– Macro (drug possession laws)

– Meso (laws governing access to NSP and OST)

– Micro (policing practices)

Strathdee et al, Lancet 2010

Global Variations in Approaches to Responding to

Drug Related Harms • 14 countries: legislation allows judicial

corporal punishment for drug and alcohol offences

• One country: has laws prohibiting OST• 30 countries: have adopted at least

some form of drug policy experimentation and/or depenalization

Werb et al, BMJ Open 2013

“Despite increased investments in enforcement-based supply reduction, illegal drug prices have generally decreased while drug purity has generally increased since 1990, suggesting that efforts to control illegal drug markets through law enforcement are failing.”

Effects of criminalization on HIV risk

– Disrupts access to harm reduction and other evidence-based prevention and treatment programs

– Drives PWID away from preventative medical care

– Reinforces stigma and discrimination

– Increases risks associated with injection drug use

The HIV risk environment • Levels:

– Macro (drug possession laws)

– Meso (laws governing access to NSP and OST)

– Micro (policing practices)

Strathdee et al, Lancet 2010

ACCESS TO EVIDENCE-BASED HIV PREVENTION & TREATMENT

• NSP in 82 countries: yet only 5% of injections covered by sterile syringes

• OST in 71 countries: yet only 8 per 100 PWID covered with OST

Mathers et al., Lancet, 2010Degenhardt et al., 2010; UNAIDS, 2012

Eliminating laws prohibiting OST, scaling up NSP and OST to 80% coverage in one African country could prevent 29% of new HIV infections among

PWID over 5 yearsStrathdee et al, Lancet 2010

The HIV risk environment • Levels:

– Macro (drug possession laws)

– Meso (laws governing access to NSP and OST)

– Micro (policing practices)

Strathdee et al, Lancet 2010

Direct Effects of Law Enforcement on HIV Risks

Discourages PWID from carrying sterile or used syringes

Fuel risky injection via “hurried injecting”Pressures PWID to inject in unsafe spaces

(e.g., shooting galleries)Prompts risky drug and syringe storage

practices that can contribute to needlestick injuries (NSI)

Indirect Effects of Law Enforcement on HIV Risks

Displaces PWID into unsafe environments

Discourages PWID from accessing HIV prevention programs (e.g., NSP, OST)

Discourages PWID from accessing emergency response

Effects of law enforcement on HIV prevention

• National survey of NSPs in US:

– 32% report weekly clientele harassment by police– 21% report weekly confiscation of legal equipment – 10% report weekly clientele arrest en route to NSP – 20% report monthly police visit/interference w

program– 56% have no systematic way to document

problems w/ police– 25% participate in training w/police, but only 1

program evaluates training– 17% programs report at least one client

referral by police in the last year (3 programs report 6+ instances)

Beletsky et al, 2011

Extra-Legal Behaviors:Police Misconduct

• Sexual Abuse• Physical Abuse• Soliciting Bribes• Evidence Planting• Precipitating forced drug withdrawal

Of 33% who reported sexual favors for police, 86.2% of these were in exchange for not being arrested.

Tijuana Cuidad Juárez Total0%5%

10%15%20%25%30%35%40%

Percentage of Female Sex Workers In-jecting Drugs who were solicited for

sexual favors from police in the last 6 months (N=515)

Beletsky et al, 2012

A Dose-Dependent Relationship between Exposure

to Police Misconduct and Syringe Sharing among PWID

Hayashi et al, AIDS & Behavior, 2013

HIV infections averted by eliminating Police Beatings in Three Cities over 5

years

Strathdee et al, Lancet 2010.

Police Perspective • Fear of needle stick injury (NSI) and

other occupational risks • Poor knowledge of infectious disease

transmission• Often unaware of evidence

demonstrating effectiveness of harm reduction, laws relating to syringe purchase and possession and availability and location of local harm reduction services

Beletsky et al, 2005

Police Education Programs (PEP)Bundling occupational safety with HIV

prevention information1. Occupational Safety

• Basic infectious disease info and Prevention tips

• Glove and sharps containers distribution

2. Law relating to harm reduction efforts (e.g., syringe possession)

3. Public health rationale for harm reduction efforts Service referral information

4. Law Enforcement and HIV Network (LEAHN) Statement of Support

Davis & Beletsky, 2009

PEP Outcomes in Kyrgyzstan (n=319)

Having undergone training is independently associated with: Intent not to confiscate syringes from

PWID Intent to refer PWID and SWs to public

health programs Institutional occupational safety

procedures Additional research needed to

determine if PEPs are associated with changes in problematic police behaviors

Beletsky et al, 2012

• Laws and policies that criminalize drug use and possession undermine access to harm reduction and are key drivers of HIV risks among PWID.

• Policing practices are a pervasive barrier to the implementation and effectiveness of harm reduction programs

Conclusions

• Policy and legal reforms that promote public health over the criminalization of drug use and PWID are urgently needed and need rigorous evaluation

• There is an urgent need to re-align harm reduction and law enforcement approaches to support prevention and treatment of HIV and viral hepatitis among PWID

Recommendations

People who use drugs who have shared their stories of abuse, humiliation, violence, torture, and loss

National Institute on Drug Abuse grants R37 DA019829, R01DA011591 and R01DA021525

Open Society Foundation

Nick Crofts and the Law Enforcement and HIV Network (LEAHN)

Acknowledgements